CASE REPORT

MASSIVE HAEMOPTYSIS IN
PULMONARY MYCETOMA
WITH PREVIOUS
TUBERCULOSIS INFECTION

M D Krisanti 1 , A Widyoningroem 2
Radiology Resident 1 , Radiology Staff 2
Department of Radiology, Airlangga University,
Dr. Soetomo General Hospital Surabaya
 INTRODUCTION

Pulmonary mycetoma (fungus ball) consist of a dense ball of

fungal filaments and amorphous material which fill a
preexisting pulmonary cavity, most commonly tuberculous
cavities. 1,2
Imaging finding : a round/oval mass with soft-tissue opacity
within a lung cavity which is separated from the wall of the
cavity by an crescent-like airspace (air crescent or Monad
sign). 2,3
Severe and life-threatening haemoptysis may occur,
particularly underlying tuberculosis. 4
Surgical resection is indicated for patients with severe life-
threatening hemoptysis. 3
 CASE REPORT

A 26 years old male patient with previous tuberculosis

infection, treated by ATT on 2011 and 2015

chronic haemoptysis for 2 years getting worse in the last 4 months

emergency room (May 2016) due to massive hemoptysis (>400 ml)

Laboratories
Radiologic finding CT guided FNAB
finding

Pulmonary mycetoma with previous tuberculosis infection

 Radiologic Finding

Chest X-ray (Fig-1) :

consolidation with a crescent of air (arrow)
in apex of the left lung surounded by
infiltrates and fibrotic fields.

Fig-2 Fig.1

CT angiography (Fig 2) :
hypervascularization peripheral
Fig. 2 fungus ball (arrow)
 RADIOLOGIC FINDING

Fig-3a

Fig-3d Fig-3b Fig-3c

CT scan (a-c) on February 2016 confirmed a mass in cavitary lesion

surrounded by an crescent of air (Monad sign) in upper lobe of the left
lung suggestive of fungus ball and showed fibrotic fields with
infiltrates and cavities in both lung. On May 2016 (d) air crescent sign
is not clearly seen, continued with CT guided FNAB
 Laboratories Finding

Sputum smear and culture : negative for AFB, negative for fungi,
positive for Stenotrophomonas Maltophilia . GeneXpert test : negative
. Anti HIV (Elisa) : non reaktif
Hb 5,5 g/DL (previous Hb 10,3 g/DL) blood transfusion Hb 8,4
g/DL

CT guided FNAB (Fig 4) :

Fig.4 wide necrotic specimen with fungal hyphae and
mononuclear cells revealed fungal infection

Treated with itraconazole and planned to left upper lobectomy.

 DISCUSSION

Pulmonary mycetomas occur most commonly in preexisting

tuberculous cavities.1,3 In our case, patient complaints chronic
haemoptysis with history of tuberculosis infection.
Radiologic examination showed a lesion with Monad sign in upper
lobe of the left lung suggestive fungus ball.
Sputum culture and smear result were negative for AFB and fungi.
In that stage our confusion was whether the lesion was a mycetoma

We went for CT guided FNAB which revealed fungal hyphae.

 DISCUSSION

From multidisciplinary discussion, microbiology department

assume active fungal infection. Aspergillus is one of the more
common cause. 1
Patient treated with oral itraconazole 200 mg daily.
Itraconazole may be useful in preventing or treating life-
threatening with comparatively minimal risk in terms of
tolerance. 5
Massive hemoptysis necessitates surgical intervention or
arterial embolization. 1,3 Left upper lobectomy was done since
the patient was having massive hemoptysis which is life-
threatening.
 CONCLUSION

Pulmonary mycetomas occur most commonly in preexisting

tuberculous cavities and aspergillus is the more common
cause.

Haemoptysis could be life-threatening. In cases of massive

hemoptysis, surgical intervention may be required as our case.

Radiologic examination plays important role to defined the

fungus ball . CT scan is the choice in defining the fungus ball
particularly in fibrotic lung fields.
 REFERENCES

1. Greenberg A K.,MD, et al.Clinical Presentation of Pulmonary

Mycetoma in HIV-Infected Patients.CHEST journal.Sept 2002 .
http://journal.publications.chestnet.org/article.aspx?articleid=1080892
2. Muller N L, et .Imaging of Pulmonary Infection. 2007. Lippincott
Williams & Wilkins
3. Kousha M. et al .Pulmonary aspergillosis : a clinical review. Eur Resp
Rev 2011. http://err.ersjournals.com/content/20/121/156
4. Franquet et al. Spectrum of Pulmonary Aspergillosis : Histologic,
Clinical,and Radiologic Findings. RadioGraphics. July 2001.
http://pubs.rsna.org/doi/full/10.1148/radiographics.21.4.g01jl03825
5. Denning D W. et al. Chronic pulmonary aspergillosis : rationale and
clinical guidelines for diagnosis and management. Eur Resp J 2015.
http://erj.ersjournals.com/content/early/2015/12/22/13993003.00583-
2015
TERIMAKASIH